Common use of Voluntary Disenrollment Clause in Contracts

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative at your center. You will be asked to sign a Department approved disenrollment form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollment. If you are disenrolled due to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverage.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative at your center. You will be asked need to sign a Department approved disenrollment form (see Appendix H)form, which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance program benefit, including the Hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, pay or fail to make satisfactory arrangements to pay, pay any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process LIFE after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar 30-day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar 30-day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollment. If you are disenrolled due to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverage.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative at your center. You will be asked to sign a Department approved disenrollment form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment. You may not enroll or disenroll from LIFE at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service areaarea or are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet nursing facility level of care as determined by the eligibility requirements for the programDepartment and are deemed not eligible. • The LIFE program agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 30-calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 30-calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department or the Department’s designee to reinstate the participant you in other Medicare and Medical Assistance Programs for which the participant is you are eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollmentappeal. If you are disenrolled due to failure to pay the premiumyour premium or payment toward cost of care, you can re-enroll remain enrolled simply by paying the amount owed in full. Provided you make this payment full before the effective date of your disenrollment, there will be with no break in coverage.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrollingThe CICO shall have a mechanism for receiving timely information about all Disenrollments from the CICO’s plan, you should discuss this with a program representative at your centerincluding the effective date of Disenrollment, from CMS and SCDHHS or its authorized agent. You All Disenrollment-related transactions will be asked performed by SCDHHS or its authorized agent consistent with the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance. Enrollees may elect to sign a Department approved disenrollment form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause the CICO or the Demonstration at any timetime and enroll in another CICO, a Medicare Advantage plan, PACE (if eligible and resides within the appropriate geographic area); or may elect to receive services through Medicare fee-for-service and a prescription drug plan and to receive Medicaid services in accordance with the South Carolina State Plan and any waiver programs (if eligible). Your disenrollment will be effective Disenrollment requests received by SCDHHS or its authorized agent, or by CMS or its CICO, either orally or in writing, by the first last calendar day of the month will be effective on the first calendar day of the following the date your LIFE Provider receives notice of your voluntary disenrollmentmonth. You The CICO may not request Disenrollment on behalf of an Enrollee. The CICO shall be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of Disenrollment. The CICO may not interfere with the Enrollee’s right to disenroll from LIFE at a Social Security officethrough threat, intimidation, pressure, or otherwise. Your social worker will assist you in returning Discretionary Involuntary Disenrollment: 42 C.F.R. § 422.74 and Sections 40.3 and 40.4 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance provide instructions to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the CICO on discretionary involuntary disenrollment. You This Contract and other guidance provide procedural and substantive requirements the CICO, SCDHHS, and CMS must follow prior to involuntarily disenrolling an Enrollee. If all of the procedural requirements are met, SCDHHS and CMS will decide whether to approve or deny each request for involuntary disenrollment based on an assessment of whether the particular facts associated with each request satisfy the substantive evidentiary requirements. Basis for Discretionary Involuntary Disenrollment: Disruptive conduct: When the Enrollee engages in conduct or behavior that seriously impairs the CICO’s ability to furnish Covered Items and Services to either this Enrollee or other Enrollees and provided the CICO made and documented reasonable efforts to resolve the problems presented by the Enrollee. Procedural requirements: The CICO’s request must be in writing and include all of the supporting documentation outlined in the evidentiary requirements. The process requires three (3) written notices. The CICO must include in the request submitted to SCDHHS and CMS evidence that the first two (2) notices have already been sent to the Enrollee. The notices are: Advance notice to inform the Enrollee that the consequences of continued disruptive behavior will be disenrollment. The advance notice must include a clear and thorough explanation of the disruptive conduct and its impact on the CICO’s ability to provide services, examples of the types of reasonable accommodations the CICO has already offered, the Grievance procedures, and an explanation of the availability of other accommodations. If the disruptive behavior ceases after the Enrollee receives notice and then later resumes, the CICO must begin the process again reinstate the process. This includes sending another advance notice. Notice of intent to request the Department and CMS’ permission to disenroll the Enrollee; and A planned action notice advising that CMS and SCDHHS have approved the CICO’s request. This notice is not a procedural prerequisite for approval and should not be sent under any circumstances prior to the receipt of express written approval and a disenrollment transaction from CMS and SCDHHS. The CICO must provide information about the Enrollee, including age, diagnosis, mental status, functional status, a description of his or her social support systems, and any other relevant information. The submission must include statements from providers describing their experiences with the Enrollee (or refusal in writing, to provide such statements); and Any information provided by the Enrollee. The Enrollee can provide any information he/she wishes. If the CICO is requesting the ability to decline future Enrollments for this individual, the CICO must include this request explicitly in the submission. Prior to approval, the complete request must be reviewed by SCDHHS and CMS including representatives from the Center for Medicare and must include staff with appropriate clinical or medical expertise. Evidentiary standards; At a minimum, the supporting documentation must demonstrate the following to the satisfaction of both SCDHHS and CMS staff with appropriate clinical or medical expertise: The Enrollee is presently engaging in a pattern of disruptive conduct that is seriously impairing the CICO’s ability to furnish Covered Items and Services to the Enrollee and/or other Enrollees. The CICO took reasonable efforts to address the disruptive conduct including at a minimum: Documentation of no fewer than three (3) separate and distinct attempts to understand and address the Enrollee’s underlying interests and needs reflected in his/her disruptive conduct and provide reasonable accommodations as defined by the Americans with Disabilities Act including those for individuals with mental and/or cognitive conditions. An accommodation is reasonable if it is efficacious in providing equal access to services and proportional to costs. SCDHHS and CMS will determine whether the reasonable accommodations offered are sufficient; A documented provision of information to the individual of his or her right to use the CICO’s Grievance procedures; and The CICO provided the Enrollee with a 30 calendar day written reasonable opportunity to cease his/her disruptive conduct. The CICO must provide evidence that the Enrollee’s behavior is not related to the use, or lack of use, of medical services. The CICO may also provide evidence of other extenuating circumstances that demonstrate the Enrollee’s disruptive conduct. Limitations: The CICO shall not seek to terminate Enrollment because of any of the following: The Enrollee’s uncooperative or disruptive behavior resulting from such Enrollee’s special needs unless treating providers expressly document their belief that there are no reasonable accommodations the CICO could provide that would address the disruptive conduct. The Enrollee exercises the option to make treatment decisions with which the CICO or any health care professionals associated with the CICO disagree, including the option of declining treatment and/or diagnostic testing. An adverse change in an Enrollee’s health status or because of the Enrollee’s utilization of Covered Items and Services. The Enrollee’s mental capacity is, has, or may become diminished. Fraud or abuse: When the Enrollee provides fraudulent information on an Enrollment form or the Enrollee willfully misuses or permits another person to misuse the Enrollee’s ID card. The CICO may submit a request that an Enrollee be involuntarily disenrolled if an Enrollee knowingly provides on the election form fraudulent information that materially affects the individual's eligibility to enroll in the CICO; or if the Enrollee intentionally permits others to use his or her Enrollment card to obtain services under the CICO. Prior to submission, the CICO must provide to CMS/SCDHHS credible evidence substantiating the allegation that the Enrollee knowingly provided fraudulent information or intentionally permitted others to use his or her card. The CICO must immediately notify the CMT so that the Enrollment broker and the HHS Office of the Inspector General may initiate an investigation of the alleged fraud and/or abuse. The CICO must provide notice to the individual prior to submission of the request outlining the intent to request disenrollment with an explanation of the basis of the CICO’s decision and information on the Enrollee’s access to Grievance procedures and a fair hearing. Necessary consent or release: When the Enrollee knowingly fails to complete and submit any necessary consent or release allowing the CICO and/or Providers to access necessary health care and service information for the purpose of compliance with the care delivery system requirements in Section 2.5 of this Contract. The CICO may request that an Enrollee be involuntarily disenrolled if the Enrollee knowingly fails to complete and submit any necessary consent or release allowing the CICO and/or Providers to access necessary health care and service information for the purpose of compliance with the care delivery system requirements in Section 2.5 of this Contract. The CICO must provide notice to the Beneficiary prior to submission of the request outlining the intent to request disenrollment with an explanation of the basis of the CICO’s decision and information on the Enrollee’s access to Grievance procedures and a fair hearing. SCDHHS and CMS shall terminate an Enrollee’s coverage upon the occurrence of any of the conditions enumerated in Section 40.2 of the 2013 Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this section, the CMT shall not be responsible for processing Disenrollments under this section. Further, nothing in this section alters the obligations of the parties for administering Disenrollment transactions described elsewhere in this Contract. The CICO shall notify SCDHHS or its authorized agent of any Enrollee whom the CICO believes is no longer eligible to remain enrolled in the CICO due to any of the following events that would give rise to ineligibility per CMS the Medicare- Medicaid Plan Enrollment and Disenrollment Guidance, in order for SCDHHS or its authorized agent to disenroll the Enrollee. The CICO shall notify SCDHHS when an Enrollee has health care insurance coverage with the CICO or any other carrier: Within fifteen (15) Business Days when an Enrollee is verified as having Duplicate Coverage with the CICO, as defined herein. Within fifteen (15) business days of the date when the CICO becomes aware that an Enrollee has any health care insurance coverage with any other insurance carrier. The CICO is not responsible for the determination of Comparable Coverage, as defined herein. SCDHHS will involuntarily terminate the Enrollment of any Enrollee with Duplicate Coverage or Comparable Coverage as follows: When the Enrollee has Duplicate Coverage that has been verified by your LIFE ProviderSCDHHS, SCDHHS shall terminate Enrollment retroactively to the beginning of the month of Duplicate Coverage. Your disenrollment will When the Enrollee has Comparable Coverage which has been verified by SCDHHS, SCDHHS shall terminate Enrollment prospectively. The Enrollment of any Enrollee under this Contract shall be effective terminated if the Enrollee becomes ineligible for Enrollment due to a change in eligibility status. When an Enrollee’s Enrollment is terminated for eligibility, the termination shall be effective: The first (1st) day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment eligibility is terminated, you must continue lost or person determined to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area Service Area; Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. When an Enrollee remains out of the Service Area or for whom residence in the Service Area cannot be confirmed for more than 30 days without prior approved arrangementssix (6) consecutive months. An independent review entity will review When an Enrollee no longer resides in the involuntary disenrollmentService Area, except for a Participant living in the Service Area who is admitted to a nursing facility outside the Service Area and placement is not based on the family or social situation of the Enrollee. If you an Enrollee is to be disenrolled at the request of the CICO under the provisions of this Section, the CICO must first provide documentation satisfactory to SCDHHS and CMS that the Enrollee no longer resides in the Service Area. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month prior to the month in which SCDHHS and CMS determine that the Enrollee no longer resides in the Service Area. Termination may be retroactive if SCDHHS and CMS are disenrolled due able to failure determine the month in which the Enrollee moved from the Service Area. When CMS or SCDHHS is made aware that an Enrollee is incarcerated in a county jail, South Carolina Department of Corrections facility, or Federal penal institution. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month during which the Enrollee was incarcerated. The termination or expiration of this Contract terminates coverage for all Enrollees with the CICO. Termination will take effect at 11:59 p.m. on the last day of the month in which this Contract terminates or expires, unless otherwise agreed to pay in writing by the premium, you can reParties. When the CMT approves a request based on information sent from any party to the Demonstration showing that an Enrollee has materially misrepresented information regarding third-enroll simply by paying party reimbursement coverage according to Section 40.2.6 of the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverageMedicare-Medicaid Plan Enrollment and Disenrollment Guidance.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative your social worker. You may disenroll from {PACE Organization} without cause at your centerany time. You will be asked need to sign a Department approved disenrollment “Disenrollment Form”. This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective {PACE Organization} after midnight on the first last day of the month following the date your LIFE Provider receives notice of your voluntary disenrollmentmonth. You Please note that you may not disenroll from LIFE {PACE Organization} at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE We may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, enrollment with {PACE Organization} if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the {PACE Organization} service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in {include zip codes or other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan identifying information here} or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangementsapproval (see CHAPTER 6). An independent review entity • You engage in disruptive or threatening behavior, i.e. your behavior jeopardizes the health or safety of yourself or others or you consistently refuse to comply with the terms of your Plan of Care or Enrollment Agreement, when you have decision-making capacity. Disenrollment under these circumstances is subject to prior approval by the DHCS and will review be sought in the event that you display disruptive interference with care planning or threatening behavior which interferes with the quality of PACE services provided to you and other PACE Participants. • You are determined to no longer meet the Medi-Cal Nursing Home level of care criteria and are not deemed eligible. • You fail to pay or fail to make satisfactory arrangements to pay any premium due to {PACE Organization} within the 30-day period specified in any Cancellation Notice (see CHAPTER 9). • The agreement between {PACE Organization}, the Centers for Medicare and Medicaid Services and the DHCS is not renewed or is terminated. • {PACE Organization} is unable to offer health care services due to the loss of our State licenses or contracts with outside providers. All rights to benefits will stop at midnight on the last day of the month following a voluntary or involuntary disenrollment. If you are disenrolled disenrollment (except in the case of termination due to failure to pay fees owed, see CHAPTER 9). We will coordinate the premiumdisenrollment date between Medicare and Medi-Cal, if you can reare eligible for both programs. You are required to use {PACE Organization} services (except for Emergency Services and Urgent Care provided outside our service area) until termination becomes effective. If you are hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, {PACE Organization} has the responsibility for service provision until you are reinstated with Medicare and Medi-enroll simply Cal benefits (according to your entitlement and eligibility). Your coverage by paying the amount owed in full{PACE Organization} is continuous indefinitely (with no need for renewal). Provided you make this payment before the effective date of disenrollmentHowever, there your coverage will be no break in coverage.terminated if:

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative your social worker. You may disenroll from FHCN PACE without cause at your centerany time. You will be asked to sign a Department approved disenrollment “Disenrollment Form”. This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFEFHCN PACE after midnight on the last day of the month. You may voluntarily disenroll from LIFE without cause at any time. Your The effective date of your disenrollment will be effective the first day of the month following the date we receive your LIFE Provider receives notice of your voluntary disenrollmentdisenrollment notification. You Please note that you may not enroll or disenroll from LIFE FHCN PACE at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE We may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, enrollment with FHCN PACE if: • ● You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the FHCN PACE service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangementsapproval (see CHAPTER 6). An independent review entity ● You or your caregiver engage in disruptive or threatening behavior, i.e., your behavior jeopardizes the health or safety of yourself or others or you consistently refuse to comply with the terms of your Plan of Care or Enrollment Agreement, when you have decision-making capacity. Disenrollment under these circumstances is subject to prior approval by the DHCS and will review be sought in the event that you or your caregiver display disruptive interference with care planning or threatening behavior that interferes with the quality of PACE services provided to you and other PACE Participants. ● You are determined to no longer meet the Medi-Cal Nursing Home level of care criteria and are not deemed eligible. ● You fail to pay or fail to make satisfactory arrangements to pay any premium due to FHCN PACE, any applicable Medicaid spend down liability, or any amount due under the post- eligibility treatment of income process, within the 30-day period specified in any Disenrollment Notice (see CHAPTER 9). ● The agreement between FHCN PACE, the Centers for Medicare and Medicaid Services and the DHCS is not renewed or is terminated. ● FHCN PACE is unable to offer health care services due to the loss of our state licenses or contracts with outside providers. All rights to benefits will stop at midnight on the last day of the month following a voluntary or involuntary disenrollment. We will coordinate the disenrollment date between Medicare and Medi-Cal if you are eligible for both programs. You are required to use FHCN PACE services (except for Emergency Services and Urgent Care provided outside our service area) and to pay the monthly fee, if applicable, until disenrollment becomes effective. FHCN PACE will continue to provide all necessary services until the disenrollment is effective. If you are disenrolled due hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, FHCN PACE has the responsibility for service provision until you are reinstated with Medicare and Medi-Cal benefits (according to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverageyour entitlement and eligibility).

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative the social worker at your PACE center. You will be asked to sign a Department approved disenrollment form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE AllCare PACE at a any Social Security office. You will need to sign a Disenrollment Form. This form will indicate that you are no longer entitled to services through AllCare PACE as of the date when your disenrollment is effective. Your social worker will confirm this date and assist you in returning to the appropriate fee-for-service Medicare and/or Medical Assistance ProgramMedicaid system. The It is to your benefit to provide 30-day notice of your intent to disenroll. This will allow time for your health and social services to be appropriately coordinated and medical care established with another provider. If, after enrolling as an AllCare PACE participant, you elect to enroll in any other Medicare or Medical Assistance Program you enroll into upon Medicaid plan or optional benefit, including Prescription Drug Coverage or a Hospice Program, your enrollment in the other plan will be considered a voluntary disenrollment from LIFE may not provide you with the full range of services available to you through LIFEAllCare PACE. Your LIFE Provider Involuntary Disenrollment AllCare PACE can terminate your benefitsbenefits by notifying you in writing of our intent to disenroll you, if: • You move out of the LIFE our designated service area. • You consistently do not comply with your individual care plan and/or terms are out of this agreement and are competent to make decisions our designated service area for yourself. • You or your caregiver engage in disruptive or threatening behaviormore than 30 days without prior approved arrangements. • You fail to pay, pay your monthly private pay premiums within a 30 day grace period or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, pay your premiums. • Your behavior threatens your health and safety or any amount due under the post-eligibility treatment health and safety of income process after a 30-day grace periodothers and cannot be managed even with the support of AllCare PACE. • You are out of the service area accepted for more than 30 consecutive days without prior approval from your LIFE Provideradmission to a state psychiatric hospital. • You are admitted to an Enhanced Care Facility (ECF). Enhanced care is designed to provide 24 hour supervision and support to eligible individuals who demonstrate challenging behaviors and psychiatric symptoms. • You become incarcerated • You no longer meet state eligibility criteria and the eligibility requirements for the county or state case manager does not believe that disenrollment will result in deterioration of your health. • You attempt to buy or sell methadone or other controlled substances, resulting in discharge from a contracted methadone maintenance or substance abuse treatment program. • The agreement with the CMS and the Department is terminated. • LIFE AllCare PACE loses the contracts and/or licenses enabling it to offer health care services. Before • AllCare PACE’s agreement with Medicare or Medicaid is not renewed or is terminated. • AllCare Health determines not to continue the AllCare PACE program. AllCare PACE must receive approval from Oregon Aging and People with Disabilities to disenroll any participant. If you are involuntarily disenrolled from LIFEdisenrolled, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your effective date of disenrollment will be effective and termination of AllCare PACE benefits is the first day of the month following month. This may change if the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for interdisciplinary team determines a longer time frame (no more than 30 days without prior approved arrangementsdays) is needed to ensure a smooth transition. An independent review entity will review the involuntary disenrollment. If you are disenrolled due to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverage.Exceptions include:

Voluntary Disenrollment. You can request to be voluntarily disenrolled from MetroPlus Managed Long Term Care at any time for any reason. You may disenroll from, or leave, the Plan for any reason by giving a notice in writing or verbally. If your notice is given verbally, MetroPlus Managed Long Term Care will confirm the notice with you wish in writing. To leave MetroPlus Managed Long Term Care you must let us know that you want to cancel your benefits by disenrollingdisenroll. MetroPlus Managed Long Term Care will contact you or the person you trust to find out the reason you no longer want to be part of the Plan, but you should discuss this with do not need to give a program representative at your centerreason if you do not want to. You will be asked to sign a Department approved disenrollment request form. This form (see Appendix H)will let you know a tentative date of disenrollment, or the date in which will indicate that you will no longer be entitled to get services through LIFEthough MetroPlus Managed Long Term Care. You may voluntarily MetroPlus Managed Long Term Care will forward your disenrollment request to New York Medicaid CHOICE to process your disenrollment. MetroPlus Health Plan will disenroll from LIFE you involuntarily (without cause at your consent) for any time. Your disenrollment will be effective the first day of the month following reasons:  You no longer live in the date your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service area. • ;  You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You enroll in another Medicaid MLTC, BCHS or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • OPWDD Day Treatment Program;  You are out of absent from the service area for more than 30 consecutive days;  You are hospitalized for 45 consecutive days without prior approval or have entered an OMH, OPWDD or OASAS residential program for 45 days or more;  You clinically require nursing home care, but are not eligible for such care under the Medicaid program’s institutional rules;  You cannot remain safely at home or in your community;  You do not require Managed Long Term Care services from MetroPlus for at least 120 days as determined by your LIFE Providerlast reassessment;  You are no longer eligible to receive New York State Medicaid benefits;  You do not pay for/or make satisfactory arrangements approved by MetroPlus Managed Long Term Care to pay spenddown amount owed to MetroPlus Health Plan after a (30) thirty day grace period;  You knowingly fail to complete and submit any necessary consents or releases as requested by MetroPlus Health Plan;  You give MetroPlus Health Plan false information that deceives the Plan or you engage in fraudulent conduct regarding any substantive or major aspect of your plan membership;  You, your family member or informal caregiver participate in any activity which jeopardizes the environment, engages in conduct or behavior which can jeopardize your health, safety or the health or safety of others. •  Your physician refuses to collaborate with MetroPlus on developing and implementing your plan of care and you do not wish to change providers.  You are not eligible for MLTC because you have been assessed as no longer demonstrating a functional or clinical need for community-based long term care services or, for non-dual eligible Enrollees, no longer meet the eligibility requirements for nursing home level of care as determined using the programassessment tool prescribed by the Department. • The agreement with An Enrollee whose sole service is identified as Social Day Care must be disenrolled from the CMS and MLTC plan. MetroPlus Health Plan shall provide the LDSS or entity designated by the Department is terminatedthe results of its assessment and recommendations regarding disenrollment within five (5) business days of the assessment making such determination. • LIFE loses Any involuntary disenrollment requires approval from New York Medicaid CHOICE (Maximus), if approved New York Medicaid CHOICE (Maximus) will notify you in writing the contracts and/or licenses enabling it to offer health care serviceseffective date of your disenrollment and your fair hearing rights. Before If you are involuntarily disenrolled from LIFEhave Medicaid, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your effective date of disenrollment from MetroPlus will be effective the first day of the month following the month in which your 30 calendar day advance notice the disenrollment request is received and is processed by the LDSS/HRA. Generally, a signed request form must be received by MetroPlus by the 15th of the month for a disenrollment endsto become effective the next month. Until the date enrollment is terminated, you must MetroPlus will continue to use the LIFE organization provide services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollment. If you are disenrolled due to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before until the effective date of disenrollment, there will be no break in coveragedisenrollment date.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative your Social Worker. You may disenroll from {PACE Program} without cause at your centerany time. You will be asked need to sign a Department approved disenrollment “Disenrollment Form” 30 days in advance of termination. This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective {PACE Program} after midnight on the first last day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment30-day notice. You We may not disenroll from LIFE at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, enrollment with {PACE Program} if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the {PACE Program} service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in {include zip codes or other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan identifying information here} or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangementsapproval (see CHAPTER SIX). An independent review entity • You engage in disruptive or threatening behavior, i.e. your behavior jeopardizes the health or safety of yourself or others or you consistently refuse to comply with the terms of your Plan of Care or Enrollment Agreement, when you have decision-making capacity. Disenrollment under these circumstances is subject to prior approval by the California Department of Health Care Services and will review be sought in the event that you, your friends or family members display disruptive interference or threatening behavior which interferes with the quality of PACE services provided to you and other PACE Participants. • You are determined to no longer meet the Medi-Cal Nursing Home level of care criteria and are not deemed eligible. • You fail to pay or fail to make satisfactory arrangements to pay any amount due to {PACE Program} within the 30-day period specified in any Cancellation Notice {see CHAPTER NINE). • The agreement between {PACE Program}, the Centers for Medicare and Medicaid Services and the California State Department of Health Care Services is not renewed or is terminated. • {PACE Program} is unable to offer health care services due to the loss of our State licenses or contracts with outside providers. Both voluntary and involuntary disenrollmentdisenrollments require a minimum 30 days’ advance notice. If you are disenrolled All rights to benefits will stop at midnight on the last day of the month following the end of the 30-day notice period (except in the case of termination due to failure to pay fees owed, see CHAPTER NINE). We will coordinate the premiumdisenrollment date between Medicare and Medi-Cal, if you can reare eligible for both programs. You are required to use {PACE Program} services (except for Emergency Services and Urgently Needed Care provided outside our service area) until termination becomes effective. If you are hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, {PACE Program} has the responsibility for service provision until you are reinstated with Medicare and Medi-enroll simply Cal benefits (according to your entitlement and eligibility). Your coverage by paying the amount owed in full{PACE Program} is continuous indefinitely (with no need for renewal). Provided you make this payment before the effective date of disenrollmentHowever, there your coverage will be no break in coverage.terminated if: (1) you fail to pay or fail to make satisfactory arrangements to pay any amount due {PACE Program} after the 30-day grace period (see CHAPTER NINE), (2) you voluntarily disenroll (see CHAPTER TEN), or

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative your social worker. You may disenroll from CEI PACE without cause at your centerany time. You will be asked need to sign a Department approved disenrollment “Disenrollment Form.” This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective CEI PACE after midnight on the first last day of the month following the date before your LIFE Provider receives notice of your voluntary disenrollmentdisenrollment date. You We may not disenroll from LIFE at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, enrollment with CEI PACE if: • You move out of the LIFE CEI PACE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Providerthe interdisciplinary team. • You engage in disruptive or threatening behavior that interferes with the quality of PACE services provided to you or other PACE Participants, i.e., your behavior jeopardizes the health or safety of yourself or others. • You consistently refuse to comply with the terms of your Care Plan or Enrollment Agreement, when you have decision-making capacity. • You are determined to no longer meet the eligibility requirements Medi-Cal Nursing Home level of care criteria and are deemed not eligible for PACE. • You fail to pay or fail to make satisfactory arrangements to pay any amount due to CEI PACE within the programperiod specified in any Loss of Medi-Cal Eligibility and/or Failure to Pay Monthly Premium letter (see CHAPTER 9). • The agreement with between CEI PACE, the CMS Centers for Medicare and Medicaid Services, and the Department DHCS is not renewed or is terminated. • LIFE loses the contracts and/or licenses enabling it CEI PACE is unable to offer health care servicesservices due to the loss of our State licenses or contracts with outside providers. Before you are involuntarily disenrolled from LIFE, Involuntary disenrollment requires advance notice. All rights to benefits will stop at midnight on the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first last day of the month following the month in which your 30 calendar day advance end of the notice of period. We will coordinate the disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other between Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal Medi-Cal, if you are involuntary disenrolled eligible for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing both programs. You are required to pay or make satisfactory arrangements to pay, or if you are out of the use CEI PACE services (except for Emergency Services and Urgent Care provided outside our service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollmentarea) until termination becomes effective. If you are disenrolled due hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, CEI PACE has the responsibility for service provision until you are reinstated with Medicare and Medi-Cal benefits (according to failure your entitlement and eligibility). CEI will work with you to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of resolve any problems that might lead to a disenrollment, there will be no break in coverageeither voluntary or involuntary. Please discuss your unresolved concerns with your social worker, home care nurse, or center director.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative your social worker. You may disenroll from {PACE Organization} without cause at your centerany time. You will be asked need to sign a Department approved disenrollment “Disenrollment Form” 30 days in advance of termination. This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective {PACE Organization} after midnight on the first last day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment30-day notice. You We may not disenroll from LIFE at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, enrollment with {PACE Organization} if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the {PACE Organization} service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in {include zip codes or other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan identifying information here} or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangementsapproval (see CHAPTER 6). An independent review entity You engage in disruptive or threatening behavior, i.e. your behavior jeopardizes the health or safety of yourself or others or you consistently refuse to comply with the terms of your Plan of Care or Enrollment Agreement, when you have decision-making capacity. Disenrollment under these circumstances is subject to prior approval by the DHCS and will review be sought in the event that you, your friends or family members display disruptive interference with care planning or threatening behavior which interferes with the quality of PACE services provided to you and other PACE Participants. You are determined to no longer meet the Medi-Cal Nursing Home level of care criteria and are not deemed eligible. You fail to pay or fail to make satisfactory arrangements to pay any amount due to {PACE Organization} within the 30-day period specified in any Cancellation Notice (see CHAPTER 9). The agreement between {PACE Organization}, the Centers for Medicare and Medicaid Services and the DHCS is not renewed or is terminated. {PACE Organization} is unable to offer health care services due to the loss of our State licenses or contracts with outside providers. Both voluntary and involuntary disenrollmentdisenrollments require a minimum 30- day advance notice. If you are disenrolled All rights to benefits will stop at midnight on the last day of the month following the end of the 30-day notice period (except in the case of termination due to failure to pay fees owed, see CHAPTER 9). We will coordinate the premiumdisenrollment date between Medicare and Medi-Cal, if you can reare eligible for both programs. You are required to use {PACE Organization} services (except for Emergency Services and Urgent Care provided outside our service area) until termination becomes effective. If you are hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, {PACE Organization} has the responsibility for service provision until you are reinstated with Medicare and Medi-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverageCal benefits (according to your entitlement and eligibility).

Voluntary Disenrollment. If you wish to cancel terminate your benefits by disenrolling, you should discuss this with a program representative your social worker. • You may disenroll from On Lok Lifeways without cause at your centerany time. • You will be asked need to sign a Department approved disenrollment “Voluntary Disenrollment Form” at least 20 days in advance of termination. • This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective On Lok Lifeways after midnight on the first last day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment20-day notice. You • If you elect to receive hospice services from the Medicare program, you will also need to complete the Voluntary Disenrollment Form. • Please note that you may not disenroll from LIFE On Lok Lifeways at a Social Security office. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE Involuntary Disenrollment On Lok Lifeways may not provide you with the full range of services available to you through LIFE. Your LIFE Provider can terminate your benefits, enrollment with On Lok Lifeways if: • You move out of On Lok Lifeways’ service area (the LIFE service area. • You consistently do not comply with your individual care plan and/or terms City and County of this agreement San Francisco, the cities of Fremont, Newark and are competent to make decisions for yourself. • You or your caregiver engage Union City and all cities in disruptive or threatening behavior. • You fail to paySanta Xxxxx County, except the cities of Xxxxxx, Xxxxxx Xxxx and San Xxxxxx) without advance written notice, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangementsapproval (see Chapter Six). • You engage in disruptive or threatening behavior (i.e., your behavior jeopardizes the health or safety of yourself or others), or you consistently refuse to comply with your plan of care or the terms of the Enrollment Agreement, when you have decision-making capacity. Disenrollment under these circumstances is subject to prior approval by the California Department of Health Care Services and will be sought in the event that you, your friends or family members display disruptive interference with care planning or threatening behavior which interferes with the quality of PACE services to you and other PACE Participants. • You are determined to no longer meet the Medi-Cal nursing home level of care criteria and are not deemed eligible. • You fail to pay or fail to make satisfactory arrangements to pay any amount due to On Lok Lifeways within the 30-day period specified in any termination notice (see Chapter Nine). • The agreement between On Lok Lifeways, Centers for Medicare and Medicaid Services and California Department of Health Care Services is not renewed or is terminated. • On Lok Lifeways is unable to offer health care services due to the loss of our State licenses or contracts with outside providers. An independent involuntary disenrollment requires a minimum 20-day advance written notice from On Lok Lifeways to the Member. All rights to benefits will stop at midnight on the last day of the month following the end of the notice period (except in the case of termination due to failure to pay fees owed, see Chapter Nine). We will coordinate the disenrollment date between Medicare and Medi-Cal if you are eligible for both programs. You are required to use On Lok Lifeways’ services (except for Emergency Services and Urgent Care provided outside our service area) until termination becomes effective. If you are hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, On Lok Lifeways has the responsibility for service provision until you are reinstated with Medicare and Medi-Cal benefits (according to your entitlement and eligibility). If you believe your enrollment has been terminated due to your health status or requirement for health care services, you may request a review entity by the Commissioner of the Department of Managed Health Care (Telephone: 0-000-000-0000). Chapter Eleven Renewal Provisions Your coverage by On Lok Lifeways is continuous indefinitely (with no need for renewal). However, your coverage will review be terminated if: (1) you fail to pay or fail to make satisfactory arrangements to pay any amount due to On Lok Lifeways after the involuntary disenrollment30-day grace period (see Chapter Nine), (2) you voluntarily disenroll (see Chapter Ten), or (3) you are involuntarily disenrolled due to one of the other conditions specified in Chapter Ten. If you choose to leave On Lok Lifeways (“disenroll voluntarily”), you may be re-enrolled. To be re-enrolled, you must re-apply, meet the eligibility requirements and complete our assessment process. If you are disenrolled due to failure to pay the premiummonthly fee (see Chapter Nine), you can re-enroll by simply by paying the amount owed in full. Provided monthly fee provided you make this payment before the effective date of disenrollmentdisenrollment (see Chapter Nine). In this case, there you will be reinstated in On Lok Lifeways with no break in coverage.